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From: B. Harris)
Subject: Difficult patients: my B1 bomber  (was QT3???)
Date: 24 May 1999 07:25:21 GMT

In <> Edward Mathes
<> writes:

>Patients with difficult to discern problems are difficult patients. They
>desire a diagnosis. A label. SOmething they can concretely identify as
>"their disease".....whether one exists or not.
>Patients who are full of baloney won't listen to reason.
>Patients who are depressed won't admit it, convinced some other problem
>Patients who have an as-yet-to-be-identified problem are the most
>difficult to deal with. THey have a problem. They have symptoms. THey
>have abnormal findings on ophysical exam. They may even have some
>abnormal labs. But we cannot 'label' their problem. THen, if we do, they
>don't like the answer.
>I had a patients with multiple recurring problems.....after 1 1/2 years
>of testing, 3 admissions, several specialist evaluations, *I* came up
>with the diagnosis. Yes, I pat myself on the back for it. Familial
>Mediteranean Fever. She even responded favorably to cholchecine therapy.
>She did not like the diagnosis so left the practice.
>THAT's what I mean by "difficult".

    Yep.  Been there, done that.  Had a nattily dressed guy in his 70's
come to me once with the complaint that he was fainting all the time.
He'd get in his car to go to Wendover to drink and gamble, and in the
desert when he'd stop to relieve himself, he'd get so dizzy he'd nearly
go down.  His ankles were swelling.  Since his doctor put him on
digoxin, an ACE inhibitor, and a diuretic (furosemide) he had only
gotten more dizzy, but still, only when standing.  Driving, he always
felt fine.

   The guy's daughter figured he was on the way out from heart trouble,
but wanted to make him comfortable.  The previous doc only seemed to be
making things worse.

   I looked at the old duffer in his suspenders and Yorkshire cap and
cane, and he was pretty orthostatic, with BP down to 70 standing, and
2+ edema.  Lungs were clear and heart and pulses on exam were great.
So was the office EKG.  I take him off his diuretic, did some basic
labs, and sent him for an echo.  Normal.  In fact his heart was working
like crazy. And now his edema was much worse, with lower legs like
flower pots, pitting grossly from knee down, and his blood pressure on
standing not much better than before-- but normal lying down.

   Finally I think to ask him what he eats.  He can't really say.  His
daughter thinks he subsists at home mostly on booze.  I am beginning to
think he has wet beri-beri and Kwashiorkor.  His labs come back with
very low potassium and albumen, otherwise okay.  I take him off all
drugs and put him on megavitamins and Ensure.   A month later his blood
pressure is rock steady at 110, dizziness is gone, and so is the edema.
His daughter is unhappy that he's drinking more.  He's unhappy that the
DMV wants him for a full eval, and suspects I put them onto him (he is
right).  Alas, he shows up sober and passes his driving test.  His
daughter wants me to send home nursing to keep him from drinking.  I
point out that Medicare won't pay for it if he's mobile (which he is).
He won't go to senior support groups for alcoholism.  His daughter
wants him in a nursing home.  I point out he can't be forced if he
doesn't want to be.  His daughter is worried that he will fall while
drunk at home.  So am I but there is nothing I can do.

  She had expected him to die and leave her the house.  Instead he's
spending all his wealth in Wendover. They leave the practice, both
unhappy with me.  They bear no ill will toward the previous internist,
and I haven't started any.  The daugher blames me for not being able to
cure alcoholism, and for the fact that the man is still on the road to
Wendover, and for the last, she is probably correct (if you the reader
meet this guy head-on some day, my apologies).  And that's the end of
the story.  The moral being that we cannot know the results of our
actions, beyond the probabability that punishment and
evil-back-reaction often follow for those which make special effort to
be meritorious.  Therefore, gird up thy loins.  And know that even
then, testicular torsion and jock itch may be they lot, without any
particular benefit, and fair expense beside.

From: B. Harris)
Subject: Re: Difficult patients: my B1 bomber  (was QT3???)
Date: 25 May 1999 00:36:34 GMT

<531A3958E2DE8117.F2FCB21253B6B3E5.229D69778F2B5893@library-proxy.airne> (Jonathan R. Fox) writes:

>Remember, no good deed goes unpunished.
>Jonathan R. Fox, M.D.

   One of the truest proverbs there is.  Usually the punishment is
simple loss of your time, combined with no return (not even gratitude).
But surprisingly often it's far worse, and consists of resentment,
hatred, active new problems in your life, or some disaster in which you
realize you've inadvertantly made something worse, which (in
retrospect, of course) you realize you should have left alone.  Or
you've wasted a lot of other people's time without making any
difference (often because the new problems created have resulted in no
net gain by anyone, and a net loss of time fixing the old ones).
Sometimes all of the above.  That's REALLY why it takes a strong
constitution to perform any altruistic act, unless you have a simple
faith you're going to be rewarded in Heaven, or (at least) that you
should do this sort of thing because God wants you to, and the
consequences are His problem (and it will all work out for the better,
even if it doesn't look like it).  If you haven't got that faith (which
I personally do not), and if you're looking for rational, tangible
evidence you made the situation better on Earth by any given
philanthropic act, you're going to be disappointed a shocking amount of
the time.  A really shocking amount.

   I've thought a lot about why this is, because it's so
counterintuitive.  I've come to two tentative conclusions about the why
of it:

1) gratitude is a very short lived emotion-- the most short lived of
any of the primary human emotions.  When gratitude vies with
resentment, resentment wins every time, and thus the probability of
helping vs. hurting for any act has got to be extraordinarily high to
even break even.  People have memories like elephants for things you
bungled up in their lives, and they forget that you were trying to help
very fast.  The reason we keep reminding ourselves that it is the
thought that counts, is that we NEED to continuously remind ourselves
of this.  Since we don't really think that way, and our emotions aren't
really set up that way.  Our emotions are set up to avoid forever that
which caused us grief, just like the food ate once, and for some reason
got nausea or vomiting after.  It's may not be the food's fault, but
you're not wired to give it an even break.

2)  People have an innate feeling (probably wrong, but that doesn't
keep it from being opperative) that the universe is a zero-sum place,
so that good things come only at a price.  No pain, no gain, is how we
usually express this idea in English, and it is DEEPLY embedded.
Thus, those things which come with effort, are especially (and
irrationally) valued.  Those that come without great effort or cost or
sacrifice, are relatively (and irrationally) devalued.  We esteam that
which we work for, sweat for, suffer for.  We don't value gifts as
much.  And altruistic acts are gifts, almost by definition.  This also
goes into the pot in balancing gratitude for help vs resentment at
having things made worse.

   The corollary of all this is that the healthiest and likely the
happiest of all human relationships are trade relationships, in which
each side receives more than he gives, but still has to give a
significant amount (there are possible heavily instinct-controlled
relationships, such as that between a queen and nursing kittens, or
human mother and child, which I do not think necessarily invalidate
this).  In the absense of having your brain picked in prolactin or
something, trade relatiohships result in maximal chance of satisfaction
for everyone, while still providing help for everyone.

  Ayn Rand, bless her selfish black irrational narcissistic empathyless
heart, actually had this right.  Mutually beneficial trade best makes
for happiness, as a social policy.  Parasitism and enforced wealth
transfers, makes for unhappiness (see Communism).  Charity is a
marginal issue, due to the basic asymmetries in human values which are
discussed above.  Charity is a bad primary foundation on which to build
a moral philosophy or social policy, for this pragmatic reason and no
other.  Those who are really interested in creating human happiness, as
opposed to those who are really interested in looking like they are
altruists, will regard charity with a jaundiced and skepical and
cynical eye, and try to keep it to a miniumum (a necessary evil, if you
will).  That's rather a paradox.  But there it is.  Help (as a pure
thing, without "strings" or payment) does cause harm, far too often.
For example, if you love your children you will WANT to give them
everything-- but if you *really* love your children and are not a fool,
you won't GIVE them everything, even if you have the capability.  For
doing that will cause them harm, and do it in various (sometimes quite
subtle) ways.  It's THAT kind of paradox.

   Not understanding this paradox has causes a good deal of subtle harm
to this society, including an underclass of people who are far less
poor in material goods than the middle class during the Great
Depression, but who have a degree of social pathology which is
unparalleled in American experience.  They've been harmed by being
helped.  Reality bites.

From: B. Harris)
Subject: Re: Difficult patients: my B1 bomber  (was QT3???)
Date: 26 May 1999 05:04:33 GMT

In <> Bret Wood
<> writes:

>I am skeptical about comparisons between current poverty levels, and
>the situation during the Great Depression.  Perhaps my view is based
>on watching the population growth in Oregon over the last 30 years.
>But, during the Great Depression, people wouldn't be able to afford
>food, but they could GROW food.  My in-laws talk about getting the
>almost-spoiled food from the grocers.  Most grocers won't do that
>nowdays.  There was enough land for people to grow gardens.

   I just realized I didn't complete the thought in my last message.
There were populations who could not grow food in the Great Depression.
But they did not turn to the kind of crime we see today.  The Grape of
Wrath is not the tale of the Joad family, who are displaced from the
Oklahoma dust bowl, and find they must turn to a life of crack dealing
and gang banging to make ends meet, or at least to get the power on so
the Nintendo, color TV, and refrigerator will work.  Nor do most people
who commit crimes in East LA do so because they look like Auchwitz
inmates and are trying to score enough bread for bread.

   BTW, life in the Oakie camps was far worse than Steinbeck described
it, and Steinbeck knew it.  It would have detracted from the story to
do it realistically, because a) people would not have believed it, and
b) Steinbeck had a more complex message than that poverty is brutal and
horrid, and he couldn't address it while that message drowned out all
others.  All that being true, the Oakie camps still weren't East LA.

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